Skip to main content

Advertisement

Log in

Extradural anterior temporal fossa approach to the paranasal sinuses, nasal cavities through the anterolateral and anteromedial triangles: Combined microscopic and endoscopic strategy

  • Original Article - Neurosurgical Anatomy
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Objective

To demonstrate the utility and limitations of the extradural endoscopic–assisted anterior temporal fossa approach to the pterygopalatine fossa (PPF), infratemporal fossa (ITF), paranasal sinuses (PS), parapharyngeal region (PPR), nasal cavities (NC), epipharynx (EP), and clivus.

Methods

A frontotemporal orbitozygomatic craniotomy is performed. The dura is elevated from the cavernous sinus (CS). The anterior temporal fossa floor is drilled. Foramen rotundum and ovale are opened. The PPF is exposed and the lateral margin of inferior orbital fissure (IOF) is removed. The anterolateral triangle (ALT) is drilled and the vidian nerve (VN) is exposed. Drilling between the maxillary nerve (V2) and the VN provides access to the sphenoid sinus (SphS). The medial pterygoid plate is drilled exposing the EP. The maxillary sinus (MaxS) is opened anterior to the PPF. V2 is transposed laterally to enlarge the anteriomedial triangle (AMT). The orbital muscle of Muller is removed as well as the medial margin of the IOF, which opens the SphS. Anteriorly, the posterior ethmoid air cells are opened. Morphometric measurements evaluating the size of the ALT were done and the PS, NC, EP were explored with the endoscope.

Results

The ALT and AMT triangle provides a wide exposure of the PPF, ITF, PPR. In addition, those triangles represent a deep entry point to explore the PS, NC, and EP.

Conclusion

The ALT and AMT are useful corridors to access to the SphS, MaxS, PS, NC, and EP via a transcranial approach. The use of the endoscope through this corridor widely extend the extradural anterior temporal fossa approach which may be considered as a valuable alternative to the extended endoscopic endonasal approach for selected skull base lesions extending both intracranial and into the PS, NC and EP.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

References

  1. Al-Mefty O, Anand VK (1990) Zygomatic approach to skull-base lesions. J Neurosurg 73(5):668–673

    Article  CAS  Google Scholar 

  2. Aziz KMA, Froelich SC, Cohen PL, Sanan A, Keller JT, Van Loveren HR (2002) The one-piece orbitozygomatic approach: the MacCarty burr hole and the inferior orbital fissure as keys to technique and application. Acta Neurochir 144(1):15–24

    Article  Google Scholar 

  3. Bao X, Deng K, Liu X, Feng M, Chen CC, Lian W, Xing B, Yao Y, Wang R (2016) Extended transsphenoidal approach for pituitary adenomas invading the cavernous sinus using multiple complementary techniques. Pituitary 19(1):1–10

    Article  Google Scholar 

  4. Battaglia P, Turri-Zanoni M, Dallan I, Gallo S, Sica E, Padoan G, Castelnuovo P (2014) Endoscopic endonasal transpterygoid transmaxillary approach to the infratemporal and upper parapharyngeal tumors. Otolaryngology - Head and Neck Surgery (United States). , pp 696–702

  5. Cappabianca P, Cavallo LM, Esposito F, De Divitiis O, Messina A, De Divitiis E (2008) Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery. Adv Tech Stand Neurosurg 33:151–199

    Article  CAS  Google Scholar 

  6. Cappabianca P, Cavallo LM, Solari D, Stagno V, Esposito F, De Angelis M (2014) Endoscopic endonasal surgery for pituitary adenomas. World Neurosurgery 82(6):S3–S11

    Article  Google Scholar 

  7. Choi KJ, Ackall FY, Truong T, Cheng TZ, Kuchibhatla M, Zomorodi AR, Codd PJ, Fecci PE, Hachem RA, Jang DW (2019) Sinonasal quality of life outcomes after extended endonasal approaches to the skull base. Journal of Neurological Surgery, Part B: Skull Base 80(4):416–423

    Article  Google Scholar 

  8. Dehdashti AR, Ganna A, Witterick I, Gentili F (2009) Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: indications and limitations. Neurosurgery 64(4):677–687

    Article  Google Scholar 

  9. Dolenc V (1983) Direct microsurgical repair of intracavernous vascular lesions. J Neurosurg 58(6):824–831

    Article  CAS  Google Scholar 

  10. Dolenc VV (1989) Anatomy and surgery of the cavernous sinus. Anatomy and Surgery of the Cavernous Sinus. https://doi.org/10.1007/978-3-7091-6942-1

    Article  Google Scholar 

  11. Fernandez-Miranda JC, Gardner PA, Snyderman CH, Devaney KO, Mendenhall WM, Suárez C, Rinaldo A, Ferlito A (2014) Clival chordomas: a pathological, surgical, and radiotherapeutic review. Head Neck 36(6):892–906

    Article  Google Scholar 

  12. Froelich S, Aziz KA, Levine NB, Tew JM, Keller JT, Theodosopoulos PV (2008) Extension of the one-piece orbitozygomatic frontotemporal approach to the glenoid fossa: cadaveric study. Neurosurgery. https://doi.org/10.1227/01.neu.0000326012.91939.fb

    Article  PubMed  Google Scholar 

  13. Gardner PA, Kassam AB, Thomas A, Snyderman CH, Carrau RL, Mintz AH, Prevedello DM (2008) Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery 63(1):36–52

    Article  Google Scholar 

  14. Hakuba A, Tanaka K, Suzuki T, Nishimura S (1989) A combined orbitozygomatic infratemporal epidural and subdural approach for lesions involving the entire cavernous sinus. J Neurosurg 71(5 I):699–704

  15. Hanakita S, Chang WC, Watanabe K, Ronconi D, Labidi M, Park HH, Oyama K, Bernat AL, Froelich S (2018) Endoscopic endonasal approach to the anteromedial temporal fossa and mobilization of the lateral wall of the cavernous sinus through the inferior orbital fissure and V1–V2 corridor: an anatomic study and clinical considerations. World Neurosurgery 116:e169–e178

    Article  Google Scholar 

  16. Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R (2005) Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus. https://doi.org/10.3171/foc.2005.19.1.7

    Article  PubMed  Google Scholar 

  17. Komatsu F, Komatsu M, Di Ieva A, Tschabitscher M (2013) Endoscopic extradural subtemporal approach to lateral and central skull base: A cadaveric study. World Neurosurgery 80(5):591–597

    Article  Google Scholar 

  18. Koutourousiou M, Fernandez-Miranda JC, Vaz-Guimaraes Filho F, de Almeida JR, Wang EW, Snyderman CH, Gardner PA (2017) Outcomes of endonasal and lateral approaches to petroclival meningiomas. World Neurosurgery. https://doi.org/10.1016/j.wneu.2016.12.001

    Article  PubMed  Google Scholar 

  19. Kuan EC, Suh JD, Wang MB (2015) Empty nose syndrome. Curr Allergy Asthma Rep 15(1):1–5

    Article  Google Scholar 

  20. Kusumi M, Fukushima T, Aliabadi H, Mehta AI, Noro S, Rosen CL, Fujii K (2012) Microplate-bridge technique for watertight dural closures in the combined petrosal approach. Neurosurgery 70(2 Suppl Operative):264–269

  21. Kutlay M, Durmaz A, Özer İ, Kural C, Temiz Ç, Kaya S, Solmaz İ, Daneyemez M, Izci Y (2018) Extended endoscopic endonasal approach to the ventral skull base lesions. Clin Neurol Neurosurg 167:129–140

    Article  Google Scholar 

  22. Ohue S, Fukushima T, Kumon Y, Ohnishi T, Friedman AH (2012) Preauricular transzygomatic anterior infratemporal fossa approach for tumors in or around infratemporal fossa lesions. Neurosurg Rev 35(4):583–592

    Article  Google Scholar 

  23. Oyama K, Watanabe K, Hanakita S, Champagne P-O, Passeri T, Voormolen EH, Bernat AL, Penet N, Fukushima T, Froelich S (2020) The orbitopterygoid corridor as a deep keyhole for endoscopic access to the paranasal sinuses and clivus. J Neurosurg 1–10

  24. Rachinger W, Grau S, Tonn J-C (2010) Different microsurgical approaches to meningiomas of the anterior cranial base. Acta Neurochir 152(6):931–939

    Article  Google Scholar 

  25. Rice DH, Kern EB, Marple BF, Mabry RL, Friedman WH (2003) The turbinates in nasal and sinus surgery: a consensus statement. Ear, Nose and Throat J, 82–84

  26. Saeki N, Horiguchi K, Murai H, Hasegawa Y, Hanazawa T, Okamoto Y (2010) Endoscopic endonasal pituitary and skull base surgery. Neurol Med Chir 50(9):756–764

    Article  Google Scholar 

  27. Scheithauer MO (2010) Surgery of the turbinates and “empty nose” syndrome. GMS Current Topics in Otorhinolaryngology, Head and Neck Surgery 9:Doc03

  28. Shimony N, Gonen L, Shofty B, Abergel A, Fliss DM, Margalit N (2017) Surgical resection of skull-base chordomas: experience in case selection for surgical approach according to anatomical compartments and review of the literature. Acta Neurochir 159(10):1835–1845

    Article  Google Scholar 

  29. Taniguchi M, Hosoda K, Akutsu N, Takahashi Y, Kohmura E (2015) Endoscopic endonasal transsellar approach for laterally extended pituitary adenomas: volumetric analysis of cavernous sinus invasion. Pituitary 18(4):518–524

    Article  Google Scholar 

  30. Taylor RJ, Patel MR, Wheless SA, McKinney KA, Stadler ME, Sasaki-Adams D, Ewend MG, Germanwala AV, Zanation AM (2014) Endoscopic endonasal approaches to infratemporal fossa tumors: a classification system and case series. Laryngoscope 124(11):2443–2450

    Article  Google Scholar 

  31. Wong RH (2018) Endoscopic endonasal transrotundum middle fossa exposure: technique of transpterygoid maxillary nerve transposition. World Neurosurgery 112:131–137

    Article  Google Scholar 

  32. Yoshida K, Kawase T, Tomita T, Ogawa K, Kawana H, Yago K, Asanami S (2009) Surgical strategy for tumors located in or extending from the intracranial space to the infratemporal fossa - advantages of the transcranial approach (zygomatic infratemporal fossa approach) and the indications for a combined transcranial and transcervica. Neurol Med Chir 49(12):580–586

    Article  Google Scholar 

  33. Zhang Q, Wang Z, Guo H, Kong F, Chen G, Bao Y, Ling F (2012) Resection of anterior cranial base meningiomas with intra- and extracranial involvement via a purely endoscopic endonasal approach. ORL 74(4):199–207

    Article  Google Scholar 

Download references

Acknowledgments

We thank all the women and men who have donated their bodies for the advancement of scientific and surgical knowledge.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Thibault Passeri.

Ethics declarations

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the local Ethical Committee (Geneva Ethics Committee Board no. 11-233R, NAC 11-085R) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study formal consent is not required.

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Comments:

The authors described in detail in this article the combined microscopic and endoscopic strategy they developed to reach the paranasal sinuses and the nasal cavities through an extradural anterior temporal fossa approach and subsequently the anterolateral and anteromedial triangles. The authors have to be congratulated for their work. They highlighted the way in which a microscopic anterior temporal fossa approach is modified into a more "extended" approach with the addition of an endoscope. This combined strategy owns several advantages to explore even through small corridors such as the antero-lateral and antero-medial triangles, the paranasal sinuses and the nasal cavities and turn around the corner to reveal blind spots.

The anatomical description, the quality of the dissection images and of the illustration are exceptional.

The 3 surgical cases nicely demonstrated the authors strategy and expertise.

A must-read article for anyone interested in skull base neurosurgery.

Michael Bruneau

Brussels

This article is part of the Topical Collection on Neurosurgical Anatomy

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Watanabe, K., Passeri, T., Hanakita, S. et al. Extradural anterior temporal fossa approach to the paranasal sinuses, nasal cavities through the anterolateral and anteromedial triangles: Combined microscopic and endoscopic strategy. Acta Neurochir 163, 2165–2175 (2021). https://doi.org/10.1007/s00701-021-04850-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-021-04850-y

Keywords

Navigation